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British Journal of Rheumatology 1997;36:260–264

OCCUPATIONAL MEDICINE & RHEUMATIC DISEASES


SERIES EDITORS: H. AVERNS and M. WEBLEY
BACK PAIN IN THE WORKPLACE
N. RATTI and K. PILLING*
Institute of Occupational Health, University of Birmingham, Edgbaston, Birmingham B15 2TT and *Rover Group Ltd, Longbridge,
Birmingham B31 2TB
K : Back pain, Workplace, Management, Occupational disease.

L back pain in the workplace takes up a high group studied epidemiologically. A French study
percentage of the occupational physician’s time; it is published in 1994 followed up 469 nurses for a period
widespread across many occupations, from heavy of 10 yr in six public sector hospitals. Using
industrial through to light office work. questionnaire analysis during that period, they found
There has been much research into the field of back that 57.9% had suffered some back pain and 40.5%
pain looking at various aetiologies, the epidemiology, had chronic relapsing back pain. From longitudinal
the effects of new and existing legislation, and the analysis, the authors concluded that not only was
success of different treatments. Despite this, if an physical workload a risk factor, but also other factors
employee is absent from work for q6 months with such as smoking, psychological stresses at work and
back pain, there is only a 50% chance of him returning even the length of commuting [5]. A further
to work. This decreases to 25% if the absence is over investigation into back injuries among nurses showed
a year [1]. In this paper, we review current literature, a 3.7 times greater prevalence among nursing personnel
attempt to clarify some grey areas, and show how an who performed stressful patient handling tasks
occupational health service can tackle this significant compared to those who did not [6].
problem. We also discuss the current management of
low back pain as practised at the Rover Group. RISK FACTORS
Previous back injury
A study looking at possible predictors in pre-em-
EPIDEMIOLOGY
ployment screening showed a history of previous back
Back pain occurs in 080% of the population at injury as the most important risk factor for future
some stage during their working life. Of this 80%, problems. This was supported by a recent paper which
fewer than 1% have a serious disease (primary bone stated that a previous history of back trouble was a
cancer, paravertebral abscesses, arthritis, trauma or much stronger predictor of future risk of back pain
cauda equina lesion) and fewer than 5% have a compared to any anthropometric data [7]. We believe
prolapsed disc—the majority of which do not need that an applicant with a history of back pain within the
surgery. Most of what remains is encompassed under last year should be seen by an occupational physician
the umbrella term mechanical back pain, although before being passed fit. Heap [6] showed that auxiliary
only a proportion have a definite mechanical nurses had a higher incidence of back injury compared
disturbance. to trained staff, probably due to delegation of manual
This is not simply a new problem that has sprung out tasks. It is no surprise that all NHS trusts have made
of the Western World in the last century due to lifting and handling courses compulsory, and some
increasing industrialization. The first recorded case of trusts are introducing a no-lifting policy.
occupational back pain was a patient of Imhotep, a
construction worker on one of the pyramids in 2780 
Work-related risk factors
[2]. Back pain as a workplace injury in the UK was first
In industry, low back pain has been the subject of
notified in the nineteenth century and the cost since
many studies looking at work-related risk factors. Risk
then has escalated. The cost of low back pain in the UK
factors looked at include the following.
has been estimated at £2000 million/year (1987–88) in
terms of lost output [3]. In the USA, it has been (a) Heavy physical/manual work. There have been
estimated that the cost in terms of medical expenses of cross-sectional studies looking at an association
each back care patient is $18 000 and an additional between heavy physical work and radiographically
$22 000 can be added in terms of interrupted income detectable lumbar disc degeneration [8, 9]. Some of
and loss of related benefits [4]. these have found an association, but other extrinsic
Nurses appear to be the most common occupational factors may have provided a bias in these studies.
Indeed, the Clinical Standards Advisory Group
Submitted 26 September 1996; accepted 29 September 1996. guidelines on low back pain [1] only recommend an
Correspondence to: K. Pilling, Rover Group Ltd, PO Box 41, X-ray if a clinical ‘red flag’ is breached. These include
Longbridge, Birmingham B31 2TB. age at onset Q20 or q55 yr, a past history of cancer,

= 1997 British Society for Rheumatology


260
RATTI AND PILLING: BACK PAIN IN THE WORKPLACE 261

F. 1.—Repetitive bending is a feature of most car assembly jobs—workers need to be fit.

weight loss, constitutional symptoms, and widespread spine, thus rendering tissues vulnerable to injury from
neurological signs. X-rays and magnetic resonance resonance. Combined with drivers taking loads to and
scanning in mechanical back pain can be very from destinations, this can lead to increased incidence
ambiguous and, despite the apparent reassurance of of low back pain [14–17].
normal radiological investigations, this can prove to be (e) Trauma. Trauma to the back may result in
counterproductive in the management of individuals. long-term mechanical and psychological effects even
Such individuals can quite easily cross over to chronic when the acute injury has healed. Some cross-sectional
illness behaviour and long-term absence without studies have shown back accidents as a causal factor
proper care [10, 11]. for back problems. A general population survey
(b) Manual handling. Manual handling carries a suggested that 16.5% of sciatica and 13.7% of
significant risk of back injury resulting from overload- mechanical back pain was due to trauma [18].
ing of tissues if the technique of lifting is incorrect. This ( f ) Psychosocial factors. Low job esteem, high
has led to regulations making the employer responsible workload, low control and pressures from managers all
for the teaching of correct lifting methods to the play an important role in the psychological aspects of
employee, which are discussed below. A study carried back pain. Cross-sectional studies have shown
out on men aged 18–55 yr who lifted at least 20 kg monotonous work and working under pressure to be
more than twice a day showed that they were at particularly associated with back pain [4]. Indeed, our
increased risk of low back pain [12]. A study of experience within motor manufacturing has shown that
three-dimensional dynamic trunk movements, covering individuals with low job esteem are the most difficult
over 400 industrial lifting jobs in 48 industries, showed to rehabilitate.
that an increase in dynamic factors such as load
movement, lifting frequency and trunk twisting INDIVIDUAL RISK FACTORS
velocity in association with a high-risk job magnified Height, weight and age have been studied as risk
the risk of low back pain by 11 times [13]. factors, and have not shown any significant associ-
(c) Twisting and bending. Twisting and bending with ation. Smoking is a habit which crosses various
loads is a significant risk factor. Video analysis of occupational groups. Some studies have shown an
workers in various industries has shown that the more association with low back pain even though some of
severe the trunk flexion whilst carrying a load, the the evidence is contradictory [19]. Animal studies have
greater the likelihood that a back injury will occur. At shown that exposure to smoking impairs nutrition of
various industries, including Rover Group, ergonomics the disc, causing metabolic changes to the disc which
has grown in importance. At Rover, associates can last up to 3 h. This can lead to increased changes
(employees) are taught the importance of ergonomics and hence injury.
and improvements in certain work processes are
suggested, thereby decreasing the incidence of musculo- SOCIAL CLASS
skeletal problems. The incidence of back pain is linked to a lack of
(d ) Whole-body vibration. Whole-body vibration in educational level. Those in social class 4 and 5 have
motor vehicle driving has been found to be a risk factor a higher frequency of low back pain, which can be
for low back pain. Vibration in motor vehicles often attributed in part to heavy manual jobs. However, a
coincides with the natural frequency of the lumbar lack of understanding of back pain and its natural
262 BRITISH JOURNAL OF RHEUMATOLOGY VOL. 36 NO. 2

course, and back care education, are also important. phases: medical screening, training (covered above) and
Therefore, we have developed Backwatchers classes at ergonomic job design.
the Longbridge Rover plant, which introduce all Medical screening looks at the individual and
aspects of back pain and its management to the attempts to direct that person away from potentially
layman. hazardous jobs, e.g. a 5 ft 6 inch person doing a
job needing constant stretching over a particular
REGULATIONS height which a 6 ft person would have no problems
There are three sets of regulations which deal with with.
back pain in the workplace, which have come into Ergonomic job design is directed at looking at the
effect since the Health and Safety at Work Act 1974 job concerned and changing it in an attempt to reduce
[20, 21]. These are: (a) The Management of Health the hazard at source. There are two principles involved:
and Safety at Work Regulations 1992 (MHSW); change the work organization to decrease the
(b) The Manual Handling Operations Regulations frequency of exposure to problem tasks or produce
1992 (MHO); (c) The Provision and Use of Work changes to the workplace to reduce the severity of the
Equipment Regulations 1992 (PUWE). task. The latter is the most obvious area where
The MHSW Regulations require the employer to ergonomic job design can contribute.
make a suitable assessment of the health and safety Various studies have looked at ergonomic interven-
risks to which the employee is exposed, including tion. Gravelling et al. [23] looked at physical and
manual handling tasks. This risk assessment acts as a physiological stress in coal face operations, and
means of identifying any action required to control the concluded that postural muscle loading was a
risks. significant factor in modern mining. Machine design
The MHO Regulations are one of the ‘six pack’ was found to be a particularly important causative
of UK regulations which came into effect in January factor in postural muscle loading and stress, so
1992. The regulations state that employers should changes to machine design were recommended.
ensure that manual handling operations are avoided Various ergonomic studies have led to industry
wherever possible; the employer should assess and realizing the importance of teaching such principles
record any hazardous operations which cannot be to employees. It is now commonplace to have
avoided, and remove or reduce risk of injury through ergonomic external consultants visiting industrial
a risk assessment. The responsibility is placed on the settings to pass on ergonomic principles.
employer to designate someone who is responsible for
the implementation of these regulations. The Rover Group experience
The PUWE Regulations place a duty on the We have introduced a system at the Rover Group
employer to ensure that work equipment is designed to Longbridge plant with the help of our German
be suitable for the task in hand. Any equipment that counterparts at BMW. This is an ergonomic risk
an employer intends to install must be within the assessment called ABA (Associate Job Analysis) and
constraints of the working environment and not takes into account various activities at the workplace.
constitute a health hazard to the employee. There are 26 criteria measured, including required
A viewpoint article in 1994 looked at the regulations height, mobility of arms, overhead work, lifting and
and the incidence of back disorders [22]. It concluded carrying, noise, climate, lighting, shift work and risk
that although the regulations are based on sound analysis. Values for illumination, noise and weights
scientific principles, the implementation of these carried are recorded.
regulations has been disappointing in terms of the A scoring system has been devised, allowing a
results. This is borne out by the continuing rise in trained assessor to tick particular boxes on a form
incidence and cost of back pain. according to the criteria being measured. By ticking a
A cursory glance at the recent Olympics, and in box with one of three abbreviations, decisions can be
particular the weight-lifting competition, would reveal made to adjust a particular workplace activity to
how important lifting techniques are. Nobody is reduce the chances of injury. The abbreviations are as
suggesting that employees should be lifting loads over follows: g = design objective met; a = action required;
three times their body weight, but poor lifting methods r = high-priority action required. All criteria of a job
obviously increase the risk of injury. Advice on how to carrying an r rating are immediately acted upon,
lift correctly is to be found in the MHO Regulations. whereas an a rating, if in isolation, would be addressed
Employers should also ensure that there are plenty of less urgently unless this was an environmental factor
visual aids around on this topic in areas where such such as noise or lighting. This allows the assessor to
tasks are performed. identify particular problem areas and recommend
action.
ERGONOMICS This system has only recently been devised, but we
Ergonomics is the study of human movement and are hopeful that it will prove successful in identifying
the co-existence of humans and machines in the potential problems.
workplace. It has a role in the rehabilitation of people We have a working population of 17 500. The
with back pain, but its prime role is in relation to the occupational health service includes two occupational
prevention of back pain. This is done in three distinct physicians, two sessional GPs, three physiotherapists,
RATTI AND PILLING: BACK PAIN IN THE WORKPLACE 263

one sports therapist, an acupuncturist, 11 full-time pieces of equipment, including traction, vibrotract
nurses and a part-time radiographer. couches, ultrasound and trophic stimulation. The
Musculoskeletal problems form the largest percent- philosophy of the department is not which technique is
age of our consultations at Rover, psychiatric problems better, but which technique is the most successful for
follow as a close second. Back pain accounts for a large a particular case. The key to the treatment in the
proportion of the musculoskeletal problems. Our department is manipulation. Backwatchers classes are
approach to its management is based on the guidelines also run through the department. This is an initiative
outlined by the Clinical Standards Advisory Group on sponsored by the National Back Pain Association with
Back Pain 1994. an aim to improve overall fitness as well as back care.
Back pain can be divided, on simple clinical grounds, Each individual is assessed, looking at blood pressure,
into three groups: simple backache, nerve root pain body weight, as well as back problems. A 30 min
and serious spinal pathology. From an occupational exercise programme is set up as well as group
physician’s point of view, we see patients from the first discussions on general back care. This is an important
two groups and become involved actively with these. concept, especially if one takes into consideration the
Patients with serious pathology can be fast-tracked to psychology of back pain. By addressing issues in a
the appropriate speciality. group, coping strategies can be discussed. Individual
Characteristics of simple backache include onset illness beliefs with respect to back pain can be
between the ages of 20 and 55 yr, mechanical nature of addressed, hopefully correcting any misconceptions
the pain, absence of constitutional symptoms and pain [25].
localized typically to the lumbosacral region. For our associates who fail to respond, we also offer
Patients in this group follow our usual pathway of a chiropractor. These associates are cross-referred by
doctor to physiotherapist and hopefully back to work. our physiotherapists, allowing an exchange of ideas.
Part of the problem we have observed is that associates Rounding off our service, we offer an acupuncture
are given variable, and sometimes incorrect, advice in service for the treatment of atypical pain. Some people
the primary care setting about back rehabilitation. The have benefited from this treatment, but it is difficult to
first doctor seen is normally the associate’s own GP, predict which individuals will be helped by acupunc-
who gives the patient an MED3 certificate and ture.
invariably tells him to rest. Trials have shown that rest Our service at Longbridge attempts to provide
for early recovery should only be 24–72 h and early numerous options in terms of treatment of back pain.
activity is the key [24]. However, it is still common This allows us to offer a complete spectrum for the
to see associates who have been told to rest for 3–6 management of back pain.
weeks.
At Rover, the associate is usually seen in a clinic COST-EFFECTIVENESS
within 2 weeks of his absence unless he self-presents A study carried out at Atomic Energy from 1987 to
earlier. Here, the doctor assesses the associate, 1991 showed that using an occupational health back
excluding any serious pathology. An immediate referral school, there was a 68% reduction in sickness absence
to the physiotherapist is possible. An associate can be due to back pain [26]. The service thus pays for itself.
seen within 24 h, a major advantage over normal GP At Longbridge, we have compared what happened in
referrals to NHS physiotherapy departments, which 1993, before the service was set up, to 1995. By looking
can take several weeks. A recommendation to change at certificates for back pain and other musculoskeletal
the associate job to an alternative job not involving disorders and estimating the cost of a day lost at work,
heavy lifting, twisting or excessive bending for a period we have been able to measure cost-effectiveness in our
of time is made to management with suggestion of department.
further review if required. This is not seen as an effort In 1993, there were 30 000 days of doctor-certified
to endorse a ‘no-work’ period, but a gradual back pain. This works out to be 1.7 days/person/year
rehabilitation to an early return to normal work. in total, and represents 16% of all certificates for that
Associates seen from the second group with nerve year. Self-certified back pain approximated to 10 000
root signs are also treated by our physiotherapy days/year, 0.5 days/person/year. Hence in 1993, 2.2
department, unless there is worsening of their days/person were lost due to back pain. For other
symptoms. Fifty per cent of these patients tend to doctor-certified musculoskeletal disorders, 18 000 days/
improve sufficiently to return to work within 6 weeks, year were lost. Self-certified musculoskeletal disorders,
some of these are referred on to the orthopaedic excluding back pain, contributed 8000 days/year. In
department, but the majority, after investigations, total, therefore, in 1993 we lost 66 000 days due to
settle with conservative measures. Future assessment musculoskeletal disorders at a total cost of £3.3 million.
may involve workplace assessment by our department In addition, the delays described above lead to
on return to work. extended sick leave for many workers.
Our physiotherapy department takes up the vast Setting up a proactive physiotherapy department in
amount of workload seen in our clinic. A total of our occupational medicine department cost £50 000 for
1400 treatments/month are dealt with in the depart- a year with a further £50 000 to cover salaries. To be
ment of which at least 50% are back problems. The cost neutral, we would have to save 2000 days.
department acts as a proactive service using various Analysis of 1995 figures shows a substantial saving.
264 BRITISH JOURNAL OF RHEUMATOLOGY VOL. 36 NO. 2

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